Patient Information Packet

GWINNETT DERMATOLOGY, PC
PATIENT INFORMATION
PATIENT INFORMATION (PLEASE PRINT)
ACCOUNT #
FIRST NAME & M. I.
LAST NAME
STREET ADDRESS
NAME CALLED BY
MARITALSTATUS
M S W D SEP
ZIP CODE
CITY AND STATE
PATIENT’S EMPLOYER
OCCUPATION
□ RETIRED
DATE OF BIRTH
□ STUDENT
EMPLOYER’S STREET ADDRESS
CITY AND STATE
ZIP CODE
IN CASE OF EMERGENCY
EMERGENCY CONTACT #
PATIENT EMAIL
REFERRED BY
PRIMARY CARE PHYSICIAN
AGE
SEX
M
F
PATIENT HOME#
PATIENT CELL#
PATIENT WORK#
OTHER FAMILY MEMBERS SEEN IN OFFICE
PERSON RESPONSIBLE FOR PAYMENT (IFDIFFERENTFROMABOVE)
LAST NAME
FIRST NAME & MIDDLE INITIAL
STREET ADDRESS
CITY AND STATE
RELATIONSHIP TO PATIENT
□ SELF □ SPOUSE □ FATHER □ MOTHER □ OTHER
ZIP CODE
HOME #
EMPLOYER
CELL #
EMPLOYER’S STREET ADDRESS
CITY AND STATE
ZIP CODE
WORK #
RELATIONSHIP TO PATIENT
□ FATHER / STEP FATHER
□ MOTHER/STEP MOTHER
□ GUARDIAN
CITY AND STATE
ZIP CODE
HOME #
COMPLETE IF PATIENT IS A MINOR OR DEPENDENT STUDENT
CONTACT NAME
STREET ADDRESS
CELL #
PATIENT PRIVACY INFORMATION
I hereby authorize Gwinnett Dermatology, P.C., and staff to leave medical information pertaining to my care by the following methods
and will assume responsibility to notify them whenever this information changes.
HOME #
CELL #
WORK #
EMAIL
Gwinnett Dermatology will only leave a message on your answering machine with your permission. May we leave a message on your answer
machine: Yes _____ No ____
I hereby authorize Gwinnett Dermatology, P.C., and staff to fax or mail medical information pertaining to my care to a referred or
referring healthcare provider and will assume responsibility to notify them whenever this information changes.
PLEASE LIST THE NAMES OF PEOPLE OUR STAFF CAN DISCUSS YOUR MEDICAL CARE WITH
SPOUSE NAME
PARENT NAME
OTHER
CONTACT PHONE #
CONTACT PHONE #
CONTACT PHONE #
I understand that I am financially responsible for all services rendered. If I am covered by an insurance company that requires a referral from my primary care physician, it
is my responsibility to obtain that referral authorization prior to my visit. I will pay the charges I am responsible for today, whether it is a copayment, deductible,
coinsurance or payment in full by the following method __Cash __Check __ Visa/MC __ Discover
____ Patient Initials
PAYMENT AUTHORIZATION I authorize insurance payment, if any, directly to Gwinnett Dermatology, PC. I realize I am responsible for non-covered services.
____ Patient Initials
INFORMATION RELEASE I authorize Gwinnett Dermatology , PC to release to my insurance carriers or to the Social Security Administration and Health Care Financing
Administration any information needed to determine benefits payable to related services. I permit a copy of this authorization to be used in place of the original, and request
payment of medical insurance benefits either to myself or to the party who accepts assignment. Regulations pertaining to Medicare assignment of benefits apply.
____ Patient Initials
ACKNOWLEDGEMENT I acknowledge all information above is accurate.
Signature of Patient or Legal Guardian, if a minor
Date
PATIENT INSURANCE INFORMATION
PRIMARY INSURANCE: (INSURANCE CARD WILL BE COPIED)
INSURANCE COMPANY NAME:
CIRCLE ONE:
HMO
POLICYHOLDER'S NAME:
POLICYHOLDER'S DATE OF BIRTH:
GROUP #
POS
EPO
INDEMNITY
RELATIONSHIP OF PATIENT TO POLICYHOLDER:
SELF
MEMBER I.D.
PPO
SPOUSE
CHILD
OTHER
CLAIMS ADDRESS (ON BACK OF CARD)
SECONDARY INSURANCE: (INSURANCE CARD WILL BE COPIED)
INSURANCE COMPANY NAME:
CIRCLE ONE:
HMO
POLICYHOLDER'S NAME:
POLICYHOLDER'S DATE OF BIRTH:
GROUP #
POS
EPO
INDEMNITY
RELATIONSHIP OF PATIENT TO POLICYHOLDER:
SELF
MEMBER I.D.
PPO
SPOUSE
CHILD
OTHER
CLAIMS ADDRESS (ON BACK OF CARD)
ACKNOWLEDGEMENT: I have reviewed the information above and acknowledge all information
is current and accurate as active insurance on my / our behalf.
Date of Patient's Visit
Patient Signature
Employee Initials
NOTICE OF PRIVACY PRACTICES
I acknowledge that I have been provided a copy of the Notice of Privacy Practices from Gwinnett
Dermatatology / Gwinnett Clinical Research Center for me to keep and that I have read (or had the
opportunity to read if I so chose) and understood the Notice. This acknowledgement is requested
per government statute.
Patient Name (please print)
Parent or Authorized Representative (if applicable)
Signature
Date
Relationship To Patient
CURRENT MEDICATION ‐ PATIENT REGISTRATION In an effort to accurately prescribe medications during your visit, we need to know the current medications you are taking. Please include herbals, vitamins, over‐the‐counter and prescriptions. Medication Dosage Frequency Start Date End Date Physician Active Why Stopped Patient Name:______________________________ DOB:____________ Date Patient Updated: ____________ Medical Assistant: ____________ Date Confirmed: ______________ (initials) CANCELLATION POLICY We value our relationship with you and we consider it a privilege that you have chosen us for your dermatologic, surgical or cosmetic needs. We want to assure its ongoing success through a mutual understanding of our cancellation policies. Office Appointments 24 hour notice of cancellation is requested. This allows us to schedule other patients who may be waiting to be scheduled. We will assess a $25 fee for No Show appointments or cancellations made with less than a 24 hour notice. This fee will not be billable to your insurance. Cosmetic Consultations Consultations for non‐surgical facial rejuvenation, all aesthetic services, including skin care, are complimentary. Please note there will be a $25 fee charged to your account if you are a No Show to your appointment or cancellation of your appointment is made with less than a 24 hour notice. This fee will not be billable to your insurance and must be paid prior to scheduling another consultation. Surgery and Cosmetic Procedures We understand that a situation may arise that could force you to cancel or postpone your surgery. Please understand that such changes affect not only your surgeon, but other patients as well. Gwinnett Dermatology will reschedule a surgery/procedure one time at no charge when notice is provided three (3) days prior to the procedure. Beyond that, there will be a $100 charge each time a surgery/procedure is rescheduled. This fee will not be applied toward your surgery/procedure and will be added as a charge to your account. This will not be billable to your insurance. Fees for in‐office treatments such as dermal fillers, neurotoxins (such as Botox®, Dysport®,Xeomin®), chemical peels, laser hair removal, vascular lasers, laser resurfacing and other similar procedures are priced either on a per treatment basis or as a treatment package, and are payable in full at the time of your appointment. Treatments and series of treatments are non‐refundable. 

In order to reserve your appointment for your cosmetic procedure, a $100 non‐refundable deposit is required at the time of the scheduling of your cosmetic procedure. Appointments for Fraxel and Bellafill Treatment require a $500 non‐refundable deposit at the time of scheduling. Cancellations three (3) days prior to procedure(s) will be subject to a fee of $100 for failing your scheduled appointment time. No fee will be charged for cancellations with more than three (3) days notice. Skin Care and Retail Products We accept returns on retail items within 7 days of product purchase for account credit only if there is a product reaction or product defect. Returns are applicable for account credit only. Unfortunately, due to the nature of the pharmaceutical preparation, we cannot accept returns on items requiring a prescription. Payment Options We accept Visa, Mastercard, Discover, Cash and Personal Checks as forms of payment. We also recommend CareCredit Patient Financing, a special program for cosmetic surgery patients. A minimum charge of $300 is required to finance your procedure with CareCredit. With CareCredit you can finance your cosmetic procedures for six months without upfront costs, annual fees, or pre‐payment penalties. Treatment of Complications The practice of medicine and surgery is not an exact science. Although good results are anticipated, there can be no guarantee or warranty, expressed or implied, by anyone as to the actual results that you may get. The results of certain procedures may not last as long as expected or meet the degree of your expected improvement. It is important that you understand that all services are non‐refundable. Surgical revisions and/or other medical treatment or management of problems and/or complications may be required. These will result in additional charges for which you will be responsible. If any touch ups are needed there will be a modest fee for set‐up, sedation, materials and medications used. The procedure itself is performed without doctor’s charges. In case of Botox we always apply a determined number of units per area that in some patients might not be enough. In case of need for extra doses of Botox a charge per extra units will be assessed. I hereby certify that I have read and that I fully understand the Gwinnett Dermatology Cancellation Policy. I understand the specific details outlined in this document clearly and I agree to be personally responsible for all cancellation fees as outlined. Patient/Responsible Party’s Signature ___________________________________________________ Date _____________________________ Witness Signature __________________________________________________________________ Date _______________________________